The most recent inspection on August 5, 2025 found the facility to be in substantial compliance following a complaint investigation. Earlier inspections generally showed the facility meeting regulatory requirements, with the exception of a March 30, 2023 annual inspection that cited deficiencies related to medication administration and dietary staff compliance with food safety. Prior reports from December 2021 noted deficiencies involving medication administration, resident supervision, and food service, including an immediate jeopardy finding related to resident elopement that was addressed with corrective actions. Complaint investigations were mostly unsubstantiated, and no fines, license suspensions, or enforcement actions were listed in the available reports. The inspection history suggests improvement over time, with recent surveys showing compliance after earlier issues were corrected.
Deficiencies (last 5 years)
Deficiencies (over 5 years)1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
An investigation of facility reported incident #117190-I and complaint #119545-C was conducted on April 22 - 23, 2024.
Findings
Incident #117190-I was not substantiated. Complaint #119545-C was not substantiated.
Complaint Details
Investigation of complaint #119545-C and incident #117190-I; both were not substantiated.
Report Facts
Incident number: 117190Complaint number: 119545
Inspection Report Plan of CorrectionDeficiencies: 0Apr 19, 2023
Visit Reason
The document is a plan of correction submitted following a prior deficiency finding, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction, effective April 6, 2023.
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #111963-C.
Findings
The facility failed to meet professional standards of quality related to medication administration and dietary staff compliance with food safety requirements. The complaint was not substantiated. Deficiencies included improper medication handling in a locked Memory Care Unit and failure of dietary male staff to wear beard restraints as required by policy.
Complaint Details
Complaint #111963 was investigated and found to be not substantiated.
Severity Breakdown
Level D: 2
Deficiencies (2)
Description
Severity
Failure to administer medications according to accepted standards of clinical practice within a locked Memory Care Unit, including leaving medications unlocked and unsupervised.
Level D
Failure to ensure dietary male staff wore beard restraints as required by food safety standards.
Level D
Report Facts
Census: 67Deficiencies cited: 2
Employees Mentioned
Name
Title
Context
Staff E
Registered Nurse (RN)
Named in medication administration deficiency for leaving medications unlocked and unsupervised
Staff F
Licensed Practical Nurse (LPN)
Interviewed regarding medication administration and ophthalmology orders
Staff G
Registered Nurse (RN)
Interviewed about medication administration expectations
Staff H
Registered Nurse (RN)
Interviewed about medication administration expectations
Dietary Manager
Named in deficiency related to dietary staff not wearing beard restraints
The inspection was conducted as a Recertification Survey and Facility Reported Incidents #97322 and #99153, including a substantiated incident #97322-1, related to medication administration and resident supervision.
Findings
The facility was found deficient in administering medications according to professional standards for 1 of 12 residents observed, and failed to provide adequate supervision and safety interventions to prevent elopement for 1 of 12 residents sampled. Additional deficiencies included improper food preparation and failure to report an elopement incident to the state.
Complaint Details
The facility reported Incident #97322-1 was substantiated. The complaint involved failure to administer medications properly and failure to provide adequate supervision leading to resident elopement. Immediate jeopardy was identified related to elopement on December 9, 2021, which was abated by implementing alarms and enhanced supervision.
Deficiencies (4)
Description
Failed to administer medications within professional standards for 1 of 12 residents observed during medication administration.
Failure to provide adequate assessment and supervision for resident who exited the building and was found outside without injuries, resulting in immediate jeopardy.
Food was incorrectly served to 2 of 3 residents, serving ground meat instead of physician-ordered pureed diet.
Failed to report an elopement for 1 of 1 residents sampled to the state within required timeframe.
Report Facts
Census: 61Residents observed for medication administration: 12Residents sampled for elopement supervision: 12Residents with food service errors: 2Residents with wandering incidents: 1
Employees Mentioned
Name
Title
Context
Susan Westmark
Administrator
Named as Administrator signing plan of correction and involved in oversight
Staff I
Certified Medication Aide
Observed placing medication cup and involved in medication administration deficiency
Staff J
Registered Nurse
Involved in medication administration observation and supervision
Staff D
Director of Nurses
Provided statements regarding medication policies and elopement supervision
Staff F
Licensed Practical Nurse
Found resident outside after elopement incident
Staff H
Certified Nurse Aide
Assisted resident back into building after elopement
A focused COVID-19 infection control survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the survey conducted from December 9 to December 10, 2020.
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an investigation of facility reported incident #91923-I and complaint #91922-C from October 14 to 20, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91922-C and facility reported incident #91923-I were not substantiated.
Complaint Details
Complaint #91922-C and facility reported incident #91923-I were investigated and found not substantiated.
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/9/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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